Comparison of pharmacy-based measures of adherence to antiretroviral therapy as predictors of virological failure

Measuring patient engagement with HIV care in sub-Saharan Africa: a scoping study

INTRODUCTION

Engagement with HIV care is a multi-dimensional, dynamic process, critical to maintaining successful treatment outcomes. However, measures of engagement are not standardized nor comprehensive. This undermines our understanding of the scope of challenges with engagement and whether interventions have an impact, complicating patient and programme-level decision-making. This study identified and characterized measures of engagement to support more consistent and comprehensive evaluation.

METHODS

We conducted a scoping study to systematically categorize measures the health system could use to evaluate engagement with HIV care for those on antiretroviral treatment. Key terms were used to search literature databases (Embase, PsychINFO, Ovid Global-Health, PubMed, Scopus, CINAHL, Cochrane and the World Health Organization Index Medicus), Google Scholar and stakeholder-identified manuscripts, ultimately including English evidence published from sub-Saharan Africa from 2014 to 2021. Measures were extracted, organized, then reviewed with key stakeholders.

RESULTS AND DISCUSSION

We screened 14,885 titles/abstracts, included 118 full-texts and identified 110 measures of engagement, categorized into three engagement dimensions ("retention," "adherence" and "active self-management"), a combination category ("multi-dimensional engagement") and "treatment outcomes" category (e.g. viral load as an end-result reflecting that engagement occurred). Retention reflected status in care, continuity of attendance and visit timing. Adherence was assessed by a variety of measures categorized into primary (prescription not filled) and secondary measures (medication not taken as directed). Active self-management reflected involvement in care and self-management. Three overarching use cases were identified: research to make recommendations, routine monitoring for quality improvement and strategic decision-making and assessment of individual patients.

CONCLUSIONS

Heterogeneity in conceptualizing engagement with HIV care is reflected by the broad range of measures identified and the lack of consensus on "gold-standard" indicators. This review organized metrics into five categories based on the dimensions of engagement; further work could identify a standardized, minimum set of measures useful for comprehensive evaluation of engagement for different use cases. In the interim, measurement of engagement could be advanced through the assessment of multiple categories for a more thorough evaluation, conducting sensitivity analyses with commonly used measures for more comparable outputs and using longitudinal measures to evaluate engagement patterns. This could improve research, programme evaluation and nuanced assessment of individual patient engagement in HIV care.

Measuring patient engagement with HIV care in sub-Saharan Africa: a scoping study

INTRODUCTION

Engagement with HIV care is a multi-dimensional, dynamic process, critical to maintaining successful treatment outcomes. However, measures of engagement are not standardized nor comprehensive. This undermines our understanding of the scope of challenges with engagement and whether interventions have an impact, complicating patient and programme-level decision-making. This study identified and characterized measures of engagement to support more consistent and comprehensive evaluation.

METHODS

We conducted a scoping study to systematically categorize measures the health system could use to evaluate engagement with HIV care for those on antiretroviral treatment. Key terms were used to search literature databases (Embase, PsychINFO, Ovid Global-Health, PubMed, Scopus, CINAHL, Cochrane and the World Health Organization Index Medicus), Google Scholar and stakeholder-identified manuscripts, ultimately including English evidence published from sub-Saharan Africa from 2014 to 2021. Measures were extracted, organized, then reviewed with key stakeholders.

RESULTS AND DISCUSSION

We screened 14,885 titles/abstracts, included 118 full-texts and identified 110 measures of engagement, categorized into three engagement dimensions ("retention," "adherence" and "active self-management"), a combination category ("multi-dimensional engagement") and "treatment outcomes" category (e.g. viral load as an end-result reflecting that engagement occurred). Retention reflected status in care, continuity of attendance and visit timing. Adherence was assessed by a variety of measures categorized into primary (prescription not filled) and secondary measures (medication not taken as directed). Active self-management reflected involvement in care and self-management. Three overarching use cases were identified: research to make recommendations, routine monitoring for quality improvement and strategic decision-making and assessment of individual patients.

CONCLUSIONS

Heterogeneity in conceptualizing engagement with HIV care is reflected by the broad range of measures identified and the lack of consensus on "gold-standard" indicators. This review organized metrics into five categories based on the dimensions of engagement; further work could identify a standardized, minimum set of measures useful for comprehensive evaluation of engagement for different use cases. In the interim, measurement of engagement could be advanced through the assessment of multiple categories for a more thorough evaluation, conducting sensitivity analyses with commonly used measures for more comparable outputs and using longitudinal measures to evaluate engagement patterns. This could improve research, programme evaluation and nuanced assessment of individual patient engagement in HIV care.

Factors affecting optimal adherence to antiretroviral therapy and viral suppression amongst HIV-infected prisoners in South Ethiopia: a comparative cross-sectional study

BACKGROUND

Maintaining optimal adherence and viral suppression in people living with HIV (PLWH) is essential to ensure both preventative and therapeutic benefits of antiretroviral therapy (ART). Prisoners bear a particularly high burden of HIV infection and are highly likely to transmit to others during and after incarceration. However, the level of treatment adherence and viral suppression in incarcerated populations in low-income countries is unknown. This study aimed to determine factors affecting optimal adherence to antiretroviral therapy and viral suppression amongst HIV-infected prisoners in South Ethiopia.

METHODS

A comparative cross-sectional study was conducted between June 1, 2019 and May 31, 2020 to compare the level of adherence and viral suppression between incarcerated and non-incarcerated PLWH. Patient information including demographic, socio-economic, behavioral, and incarceration-related characteristics were collected using a structured questionnaire. Medication adherence was assessed according to self-report and pharmacy refill. Plasma viral load measurements undertaken within the study period were prospectively extracted to determine viral suppression. Univariate and multivariate logistic and fractional regression models were used to analyse data.

RESULTS

Seventy-four inmates living with HIV (ILWH) and 296 non-incarcerated PLWH participated in the study. While ILWH had a significantly higher pharmacy refill adherence compared to non-incarcerated PLWH (89 vs 75%), they had a slightly lower dose adherence (81% vs 83%). The prevalence of viral non-suppression was also slightly higher in ILWH (6.0%; 95% confidence interval (CI): 1.7-14.6%) compared to non-incarcerated PLWH (4.5%; 95%CI: 2.4-7.5%). Overall, missing ART appointments, dissatisfaction with ART services, inability to comply with a specified medication schedule, and types of methods used to monitor the schedule (e.g., news time on radio/TV or other social cues) were significantly associated with non-adherence according to self-report. In ILWH specifically, accessing ART services from a hospital, inability to properly attend clinic appointments, depressive symptoms, and lack of social support predicted NA. Viral non-suppression was significantly higher in males, people of age 31to 35 years and in those who experienced social stigma, regardless of their incarceration status.

CONCLUSIONS

Sub-optimal dose adherence and viral suppression are generally higher in HIV-infected prisoners in South Ethiopia compared to their non-incarcerated counterparts. A multitude of factors were found to be responsible for this requiring multilevel intervention strategies focusing on the specific needs of prisoners.

Walking and perceived lack of safety: Correlates and association with health outcomes for people living with HIV in rural Zambia

INTRODUCTION

Geographic inaccessibility disproportionately affects health outcomes of rural populations due to lack of suitable transport, prolonged travel time, and poverty. Rural patients are left with few transport options to travel to a health facility. One common option is to travel by foot, which may present additional challenges, such as perceived lack of safety while transiting. We examined the correlates of perceived lack of safety when walking to a health facility and its association with treatment and psychosocial outcomes among adults living with HIV.

METHODS

Data were collected from 101 adults living with HIV in Eastern Province, Zambia. All participants were receiving antiretroviral therapy at one of two health clinics. Perceived lack of safety was measured by asking respondents whether they felt unsafe traveling to and from the health facility in which they were receiving their HIV care. Outcomes included medication adherence, perceived stress, hope for the future, and barriers to pill taking. Linear and logistic regression methods were used to examine the correlates of perceived safety and its association with health outcomes.

RESULTS

Being older, a woman, having a primary education, living farther from a health facility, traveling longer to reach a health facility, and owing money were associated with higher likelihood of feeling unsafe when traveling by foot to health facility. Perceived lack of safety was associated with medication nonadherence, higher level of stress, lower level of agency, and more barriers to pill taking.

CONCLUSIONS

Perceived lack of safety when traveling by foot to a health facility may be a barrier to better treatment and psychosocial outcomes, especially among rural patients. Practitioners and policymakers should consider implementation of differentiated HIV service delivery models to reduce frequent travel to health facilities and to alleviate ART patients' worry about lack of safety when traveling by foot to a health facility.

Medication-based Refill Adherence Among Pregnant Women Living With HIV in Nigeria

PURPOSE

A major global public health challenge is the continuance of new pediatric HIV infections primarily because of mother to child transmission of HIV occurring mainly in sub-Saharan African countries. The purpose of this study was to examine antiretroviral therapy (ART) refill adherence and its determinants among pregnant women living with HIV in Nigeria.

METHODS

A retrospective review of pharmacy refill records was undertaken to examine adherence data on 275 pregnant women undergoing ART in 4 high-volume HIV treatment sites in Nigeria. A pharmacy refill adherence measure was used to assess medication refill behavior of pregnant women living with HIV who had received an ART refill during a period of 3 months. Medication-based ART refill adherence was categorized as % adherence (100% adherence) or % nonadherence (<100% adherence) to the ART refill scheduled dates. Refill appointments were scheduled on a 28-day cycle. Multivariable logistic regression analysis was performed.

FINDINGS

Of the 275 women, 59.3% (95% CI, 53.1%-65.5%) were adherent to their ART refill schedule. Women who initiated ART during the third trimester of their current pregnancy had the lowest adherence rate of 30.8% (95% CI, 7.7%-53.8%) compared with women who commenced ART before conception or during the first or second trimester. The availability of a treatment support person was significantly associated with ART refill adherence. The odds of medication-based refill adherence were 2.9 times higher for participants who had a treatment support person (odds ratio = 2.9; 95% CI, 1.6-5.2; p = 0.001).

IMPLICATIONS

Results indicate that having a treatment support person could contribute to improving ART adherence in pregnant women living in Nigeria.

Comparative Analysis of two Methods of Measuring Antiretroviral Therapy Adherence in HIV-Infected Omani Patients

Background:

Antiretroviral therapy (ART) adherence is crucial to achieve HIV suppression and to prolong survival of HIV-infected patients. Although monitoring of ART adherence is standard of HIV care, there is yet no optimal method to measure ART adherence. Therefore, it is essential to compare the effectiveness of different adherence measurement tools to predict HIV suppression.

Methods:

In this study, we measured ART adherence using pharmacy refill prescription and self-reported adherence questionnaire. Both the methods were compared for predicting HIV suppression in adult Omani HIV-infected patients attending the outpatient clinics at Sultan Qaboos University Hospital.

Results:

A total of 141 HIV-infected patients were included. The pharmacy refill–based measure showed a median adherence rate of 98.90% (interquartile range [IQR]: 86%-99.45%). The self-report adherence questionnaire revealed a median adherence rate of 100% (IQR: 75-100). A significant positive correlation was found between the adherence rates measured by the 2 methods (r = 0.32, P = .01). The pharmacy refill and self-report questionnaire adherence measures were both negatively correlated with plasma HIV RNA levels (r = −0.20, P = .01 and r = −0.26, P = .04, respectively).

Conclusion:

Collectively, these findings suggest that pharmacy refill measure could serve as a valid and practical tool of ART adherence in routine clinical practice.

Recommended method for health services to determine adherence to antiretroviral therapy: a comparison of three models

The medication possession ratio (MPR) method is commonly used for the determination of antiretroviral medication adherence. However, different ways of calculating MPR and methodological issues hinder the interpretation of the results and the reproducibility of the method. Thus, this study used three different models of MPR calculation and aimed to identify the one that best represents the situation of patient adherence. The results show that there was a statistically significant difference between the adherence rates determined by the three models, which indicates the need to specify the parameters used for calculation in the MPR method. However, the models individually were found to be related to viral suppression, but none of them had a greater effect than the other in this regard. The model that used residual medication (RM) and a fixed period of analysis allowed for a more precise identification of the number of doses that the patient used when compared to the others. Health services should avoid the application of the model using a variable analysis period. This study found that RM and the period of analysis considered are the main influencing factors in the accuracy of adherence results when the MPR method is used.

Pharmacy Refill Data are Poor Predictors of Virologic Treatment Outcomes in Adolescents with HIV in Botswana

In adults living with HIV, pharmacy refill data are good predictors of virologic failure (VF). The utility of pharmacy refill data for predicting VF in adolescents has not been reported. We evaluated data from 291 adolescents on antiretroviral therapy. The main outcome measure was VF, defined as two consecutive HIV viral load measurements ≥ 400 copies/mL during 24-months of follow-up. Pharmacy refill non-adherence was defined as two consecutive refill adherence measurements < 95% during the same period. Fifty-three (18%) adolescents experienced VF. One hundred twenty-eight (44%) adolescents had refill non-adherence. Refill non-adherence had poor discriminative ability for indicating VF (receiver operating characteristic AUC = 0.60). Sensitivity and specificity for predicting VF was poor (60% (95% CI 46-74%) and 60% (95% CI 53-66%), respectively). The lack of a viable surrogate for VF in adolescents highlights the urgent need for more access to virologic testing and novel methods of monitoring adolescent treatment adherence.

The Association of Material Hardship with Medication Adherence and Perceived Stress Among People Living with HIV in Rural Zambia

The intersection of poverty and HIV/AIDS has exacerbated socioeconomic inequalities in Zambia. For example, the downstream consequences of HIV/AIDS are likely to be severe among the poor. Current research has relied on multidimensional indicators of poverty, which encompass various forms of deprivation, including material. Although comprehensive measures help us understand what constitutes poverty and deprivation, their complexity and scope may hinder the development of appropriate and feasible interventions. These limitations prompted us to examine whether material hardship, a more practicable, modifiable aspect of poverty, is associated with medication adherence and perceived stress among people living with HIV (PLHIV) in Zambia. We used cross-sectional data from 101 PLHIV in Lundazi District, Eastern Province. Data were collected using a questionnaire and hospital records. Material hardship was measured using a five-item scale. Perceived stress was measured using the ten-item perceived stress scale. Adherence was a binary variable measured using a visual analog scale and medication possession ratio (MPR) obtained from pharmacy data. We analyzed the data with multivariable linear and logistic regressions using multiply imputed datasets. Results indicated that greater material hardship was significantly associated with MPR nonadherence (odds ratio = 0.83) and higher levels of perceived mental distress (β = 0.34). Our findings provide one of the first evidence on the association of material hardship with treatment and mental health outcomes among PLHIV. The findings also draw attention to the importance of economic opportunities for PLHIV and their implications for reducing material hardship and improving adherence and mental health status.

Comparison of the predictive performance of adherence measures for virologic failure detection in people living with HIV: a systematic review and pairwise meta-analysis

A critical feature of an adherence assessment tool is its ability to predict virologic failure in people living with HIV (PLHIV). We, therefore, aimed to compare the predictive performance of commonly used adherence measures. We systematically searched MEDLINE, Embase and LILACS up to February 2018, to identify relevant observational studies comparing the effects of any two of the following adherence measurements on virologic outcomes: electronic monitoring, pill count, pharmacy refill, self-report and physician assessment. We analyzed data by pairwise meta-analyzes with a random-effects model. The proportion of virologic failures among non-adherent participants in each adherence measure was used to calculate the odds ratio (OR), with 95% Confidence Intervals (95%CI). Heterogeneity was assessed, with potential causes identified by sensitivity and subgroup analysis. We included 38 studies with individual patient data for 18,010 patients. All possible comparisons between pairs of the five adherence measures were considered and a total of nine comparison groups could be established. Meta-analysis suggested that self-report was a better predictor of virologic failure than pill count when the recall period was within one week (OR: 2.35, 95%CI: 1.07-5.18, p = 0.03). Physician assessment had higher odds of predicting virologic failure than did either self-report (OR: 2.63, 95%CI: 1.37-5.26, p < 0.01) or pharmacy refill (OR: 3.57, 95%CI: 1.69-7.14, p < 0.001). There was no difference in the predictive performance between any of the other measures that we were able to compare (p > 0.05). The combination of multiple measures did not increase the predictive value when compared to any of the measures alone. Low-cost and simple adherence measures such as self-report predict virologic failure better than or equally well as objective measures. Our results suggest that there is no need to use expensive or time-consuming adherence measures when the objective is to identify PLHIV at risk of treatment failure.

Implementation of Option B and a fixed-dose combination antiretroviral regimen for prevention of mother-to-child transmission of HIV in South Africa: A model of uptake and adherence to care

INTRODUCTION

Initiating and retaining pregnant women on antiretroviral therapy (ART) to prevent mother-to-child HIV transmission (PMTCT) remains a major challenge facing African HIV programs, particularly during the critical final months prior to delivery. In 2013, South Africa implemented its "Option B" PMTCT regimen (three-drug ART throughout pregnancy and breastfeeding, regardless of maternal CD4 count) and introduced once-daily fixed-dose combinations and lifelong ART. Currently, the uptake of Option B and its possible impact on adherence to PMTCT during the critical final months of pregnancy is unclear.

MATERIALS AND METHODS

We prospectively collected visit data from a cohort of adult, HIV-infected, pregnant women between July 2013-August 2014 to estimate three models of adherence to PMTCT during the final 16 weeks immediately preceding delivery. Adherence was defined according to possession of antiretroviral drugs, which was inferred from clinic visit records under varying assumptions in each model. We describe uptake of the PMTCT regimen, gestational age at initiation, and model possible scenarios of adherence through delivery after the implementation of Option B.

RESULTS

Among 138 women enrolled (median (IQR) age 28 years (24-32), median CD4 count 378 cells/mm3), median (IQR) gestational age at initiation was 22 weeks (16-26). Estimates of adherence during the final 16 weeks of pregnancy prior to delivery ranged from 75% (52-89%) under the best case scenario assumptions to 52% (30-75%) under the worst case scenario assumptions. Estimates of the proportion of women who would achieve 80% adherence to PMTCT were <50% across all models.

CONCLUSIONS

Despite the switch to Option B and once-daily dosing, South African women continue to initiate PMTCT late in pregnancy, and estimations of regimen adherence, as modelled using PMTCT visit attendance data, is poor, with <50% of women reaching 80% adherence during final months of pregnancy across all models. Further guideline changes and interventions are needed to achieve vertical transmission goals.

TRIAL REGISTRATION

ClinicalTrials.gov NCT01710397 South African National Clinical Trials Register DOH-27-0213-4177.

Barriers and facilitators of antiretroviral therapy adherence in rural Eastern province, Zambia: the role of household economic status

In Zambia, more people living with HIV now have access to lifesaving antiretroviral therapy than ever before. However, progress in HIV treatment and care has not always resulted in lower mortality. Adherence remains a critical barrier to treatment success. The objective of this study was to examine the barriers and facilitators of antiretroviral therapy adherence, particularly the role of household economic status. The study included a cross-sectional sample of 101 people living with HIV (PLHIV) in two rural communities in eastern Zambia. Adherence was measured using patient self-assessment and pharmacy information. Household economic status included components such as occupation, income, assets, food security, and debt. Multivariable logistic regression was conducted to examine the associations between household economic factors and adherence. Our findings suggest that the role of economic status on adherence appears to be a function of the economic component. Debt and non-farming-related occupation were consistently associated with non-adherence. The association between assets and adherence depends on the type of asset. Owning more transportation-related assets was consistently associated with non-adherence, whereas owning more livestock was associated with self-reported adherence. Additionally, living in a community with fewer economic opportunities was associated with non-adherence. The associations between place of residence and pharmacy refill adherence and between transportation assets and self-reported adherence were statistically significant. Improving adherence requires a multifaceted strategy that addresses the role of economic status as a potential barrier and facilitator. Programmes that provide economic opportunities and life-skills training may help PLHIV to overcome economic, social, and psychological barriers.

Larger is not necessarily better! Impact of HIV care unit characteristics on virological success: results from the French national representative ANRS-VESPA2 study

OBJECTIVES

To determine the impact of hospital caseload size on HIV virological success when taking into account individual patient characteristics.

METHODS

Data from the ANRS-VESPA2 survey representative of people living with HIV in France was used. Analyses were carried out on the 2612 (86.4% out of 3022) individuals receiving antiretroviral (ARV) treatment for at least one year. Outcomes correspond to two definitions of virological success (VS1 and VS2 respectively) and were analyzed under a multi-level modeling framework with a special focus on the effect of the caseload size on VS.

RESULTS

Structures with caseloads <1700 patients were more likely to have increased the proportion of patients achieving virological success (59% and 81% for VS1 and VS2, respectively) than structures whose caseloads numbered ≥1700 patients. Our results highlight that patients in the 11 largest care units in the sample were exposed to a context where their VS was potentially compromised by care unit characteristics, independently of both their individual characteristics and their own HIV treatment adherence behavior.

CONCLUSIONS

Our results suggest that - at least in the case of HIV care - in France large care units are not necessarily better. This result serves as an evidence-based warning to public authorities to ensure that health outcomes are guaranteed in an era when the French hospital sector is being substantially restructured.